<html py:extends="master.xhtml" py:strip="True">
    <head py:block="head" py:strip="True">
        <title py:block="master_title">Enter Symptoms</title>
    </head>

<body py:block="body" py:strip="True">
  <h1>Enter Symptoms</h1>

  <form action="${tg.url('/symptom/diagnosis')}" method="get"
    accept-charset="UTF-8" class="form-horizontal">
    <div class="panel panel-default">
      <div class="panel-heading">
        <b>1. Are they concious?</b>
      </div>
      <div class="panel-body">
        <i>
          Not everyone who gets a concussion will lose consciousness, but some
          people do.
        </i>
        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios1" id="optionsRadios1" value="option1" />
            The patient is <b>unconcious</b>
          </label>
        </div>

        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios1" id="optionsRadios1" value="option1" />
            The patient is <b>concious</b>
          </label>
        </div>
      </div>
    </div>

    <div class="panel panel-default">
      <div class="panel-heading">
        <b>2. Is their speech slurred?</b>
      </div>
      <div class="panel-body">
        <i>
          Ask the person some basic questions such as, "What is your name?" and
          "Do you know where you are?"
        </i>
        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios2" id="optionsRadios1" value="option1" />
            The patient's speech <b>is</b> slurred
          </label>
        </div>

        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios2" id="optionsRadios1" value="option1" />
            The patient's speech is <b>not</b> slurred
          </label>
        </div>
      </div>
    </div>

    <div class="panel panel-default">
      <div class="panel-heading">
        <b>3. Does the patient remember what happened?</b>
      </div>
      <div class="panel-body">
        <i>
          If the person has a blank stare, seems confused, or doesn’t know
          where they are, it could be a sign of a brain injury.
        </i>
        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios3" id="optionsRadios1" value="option1" />
            The patient is <b>confused</b>
          </label>
        </div>

        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios3" id="optionsRadios1" value="option1" />
            The patient is <b>not</b> confused
          </label>
        </div>
      </div>
    </div>

    <div class="panel panel-default">
      <div class="panel-heading">
        <b>4. Is the patient experiencing nausea or vomiting?</b>
      </div>
      <div class="panel-body">
        <i>
          If someone vomits, especially repeatedly, after being hit in the head
          or involved in another type of accident, this usually indicates a
          concussion.
        </i>
        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios4" id="optionsRadios1" value="option1" />
            The patient is <b>nauseated or vomiting</b>
          </label>
        </div>

        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios4" id="optionsRadios1" value="option1" />
            The patient is <b>not</b> nauseated or vomiting
          </label>
        </div>
      </div>
    </div>

    <div class="panel panel-default">
      <div class="panel-heading">
        <b>5. Is the patient's balance or coordination impaired?</b>
      </div>
      <div class="panel-body">
        <i>
          People with concussions often have problems with their motor skills,
          such as being unable to walk in a straight line or catch a ball.
          Check if the person is having trouble with these things or has a
          delayed reaction time.
        </i>
        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios5" id="optionsRadios1" value="option1" />
            The patient's balance or coordination <b>is</b> impaired
          </label>
        </div>

        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios5" id="optionsRadios1" value="option1" />
            The patient's balance or coordination is <b>not</b> impaired
          </label>
        </div>
      </div>
    </div>

    <div class="panel panel-default">
      <div class="panel-heading">
        <b>6. Is the victim experiencing a headache, blurred vision, or dizziness?</b>
      </div>
      <div class="panel-body">
        <i>
          A headache that lasts more than a few minutes is a common sign of a
          concussion. Blurred vision, “seeing stars,” and/or feelings of
          dizziness or fogginess may also indicate a concussion.
        </i>
        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios6" id="optionsRadios1" value="option1" />
            The patient <b>does</b> have a headache, blurred vision, or dizziness.
          </label>
        </div>

        <div class="radio">
          <label>
            <input type="radio" name="optionsRadios6" id="optionsRadios1" value="option1" />
            The patient <b>does not</b> have a headache, blurred vision, or dizziness.
          </label>
        </div>
      </div>
    </div>

    <button type="submit" class="btn btn-primary">Submit</button>
  </form>
</body>
</html>
